Background: Partial normal saline replacement during plasma exchange procedures is a common practice to reduce procedure costs but may increase the risk of adverse events, such as hypotension and citrate reactions. The goal of this study was to compare adverse event rates for the patients that used albumin or albumin/saline as replacement. Study Design and Methods: A retrospective chart review was done of plasma exchange procedures that used all albumin or 80% albumin to 20% normal saline (80/20) as replacement. The procedure type (all albumin vs 80/20), the percent of normal saline used, age, gender, and adverse events during the procedure were recorded. Results: During the study period, 3624 procedures were documented for 401 patients (46% female), age range 0 to 93 years, of which 2453 (67.7%) used 80/20. Overall 91 procedures (2.5%) resulted in a hypotensive event, 26 (0.7%) of which were classified as moderate to severe hypotension, and 40 (1.1%) had reported citrate toxicity. After adjusting for age, gender, and diagnosis using a generalized linear mixed model and backward model selection, results showed that 100% albumin had a significantly lower risk of having hypotension than 80/20 (odds ratio (OR): 0.531 [0.298, 0.946], P = 0.032) and moderate to severe hypotension (odds ratio: 0.140 [95% confidence interval (CI): 0.031, 0.628], P = 0.010). Older age was also predictive of having hypotensive reactions (OR[95%CI] = 1.017,[1.0, 1.034], P = 0.047). Conclusion: Partial saline use as a replacement fluid with albumin during plasma exchange is associated with an increased risk of hypotension. Use of saline as replacement fluid during plasma exchange should be minimized especially in older patients.

A 51-year-old man with type 2 diabetes mellitus and chronic obstructive pulmonary disease presented to the emergency room with increasing bilateral leg pain, rash, and scrotal swelling with pain. Skin biopsy from his thigh revealed IgA-associated vasculitis. Due to hematuria, a renal biopsy was performed and showed an IgA glomerulonephritis with focal fibrinoid necrosis and neutrophil accumulation. Bilateral orchiectomies were performed in two separate procedures ten and thirteen days after the renal biopsy, as a result of uncontrolled abscess formation in testicles. Microscopically, both testicles revealed large abscess formation destroying almost the entire testicular parenchyma without tumor cells. Spermatic cord margins were further scrutinized microscopically to show bilateral vasculitis in many small size vessels, confirmed by positive endothelial staining for IgA. Some of the affected arteries revealed central organizing thrombi with recanalization features, highly suggestive of vasculitis-associated thrombi formation, resulting in testicular ischemic infarction and abscess formation. We conclude that this adult patient developed a severe form of Henoch-Schönlein purpura, with vasculitis affecting multiple organs, including the most serious and unusual complication of bilateral testicular infarction.

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Integration has progressed beyond the basic concept of horizontal and vertical integration. We now emphasize student-directed learning, active learning, development of interpersonal skills, problem solving, and self-reflection. Inflammatory Bowel disease (IBD) serves as an excellent model for how we accomplish integration of histology with other disciplines, resulting in one course that is organ-system based, thus increasing the connection to clinical medicine. It has two major constituents: ulcerative colitis and Crohn's disease. It can involve any segment of the GI tract, as well as other systems that share clinical and pathological characteristics.We use clinical scenarios of IBD cases in order to make histology more clinically relevant. Students address comprehensively the anatomy, histology, histopathology, and pathophysiology in a manner that provides a thorough understanding of the disease. Then they are able to establish a final diagnosis. This approach is facilitated by making available to the students a wide variety of resources.This student-directed strategy requires a major shift in the way educators think about medical school teaching. It is a successful integration approach whereby students themselves take initiative and responsibility for determining what is worthwhile to learn. In addition to horizontal integration and vertical integration, it offers several intangible benefits. Chief among those benefits is building a community of students with high level of skills and professionalism.